From the April 2008 issue

Dose countdown misleading. In our October 2007 issue, we reported patient confusion with the dose counter of PULMICORT FLEXHALER (budesonide inhalation powder), an asthma inhaler. A patient stopped by a clinic pharmacy and commented that after several attempts to administer a dose, it felt like the inhaler was not working. The number in the dose-counter window on the inhaler did not seem to move with each dose, and when activating the inhaler, the patient “was not able to see or feel anything.” These factors contributed to the patient’s belief that a dose had not been administered. Thanks to your reports, Astra Zeneca has updated the Patient’s Instructions for Use section of the product label with more detailed information about the dose counter. An updated patient information leaflet is available at: www.pulmicortflexhaler.com/p/. All physician practices, clinics, and pharmacies should make sure they obtain sample devices from the manufacturer and that staff are familiar with how the devices work before they are prescribed or dispensed. Practitioners should incorporate this updated information, as well as return demonstrations, in patient education sessions.

To reduce the risk of mix-up, educate your colleagues about the possibility of confusing these products. Prescribers should explicitly state which dosage form they want dispensed. This could be done by indicating the salt with the name (i.e., metoprolol tartrate or metoprolol succinate) or the words “immediate release” or “extended release.” Pharmacists should communicate with patients and/or verify with the prescriber which metoprolol product is to be dispensed if it is not specified on the prescription. They should also label their inventory to differentiate immediate-release and extended-release products from one another. Be sure patients understand that various dosage forms of metoprolol exist and help them understand which one has been prescribed for them. With this information, they will be armed to provide a final verification any time the medication is dispensed.